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* '''Rhabdomyolysis''' : the breakdown and release of muscular tissue (myoglobin) into the bloodstream resulting in renal damage and the subsequent build up of toxic compounds in the blood.<ref name="pmid25829882">{{cite journal| author=Torres PA, Helmstetter JA, Kaye AM, Kaye AD| title=Rhabdomyolysis: pathogenesis, diagnosis, and treatment. | journal=Ochsner J | year= 2015 | volume= 15 | issue= 1 | pages= 58-69 | pmid=25829882 | doi= | pmc=4365849 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25829882 }} </ref> | * '''Rhabdomyolysis''' : the breakdown and release of muscular tissue (myoglobin) into the bloodstream resulting in renal damage and the subsequent build up of toxic compounds in the blood.<ref name="pmid25829882">{{cite journal| author=Torres PA, Helmstetter JA, Kaye AM, Kaye AD| title=Rhabdomyolysis: pathogenesis, diagnosis, and treatment. | journal=Ochsner J | year= 2015 | volume= 15 | issue= 1 | pages= 58-69 | pmid=25829882 | doi= | pmc=4365849 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25829882 }} </ref> | ||
* '''Compartment syndrome''' : the raised pressure (>20 mm of Hg) within a localized region causing decreased local circulation which can lead to ischemia and necrosis of that osteo-musculo-fascial compartment.<ref>Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/</ref> This can later lead to release of necrosed muscle tissue into the blood which damages the kidney and can present with features similar to crush syndrome. | * '''Compartment syndrome''' : the raised pressure (>20 mm of Hg) within a localized region causing decreased local circulation which can lead to ischemia and necrosis of that osteo-musculo-fascial compartment.<ref>Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/</ref> This can later lead to release of necrosed muscle tissue into the blood which damages the kidney and can present with features similar to crush syndrome. | ||
==Historical perspective== | |||
The first reported relations between compressive trauma and renal damage were after the 1909 earthquake in Sicily and World War I.<ref name="pmid2194135">{{cite journal| author=Better OS| title=The crush syndrome revisited (1940-1990). | journal=Nephron | year= 1990 | volume= 55 | issue= 2 | pages= 97-103 | pmid=2194135 | doi=10.1159/000185934 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2194135 }} </ref> In the year 1923, a physician named Seigo Minami reported crush syndrome after observing three soldiers who died due to renal failure as a result of injuries sustained during World War I. <ref>Medical discoveries - Who and when- Schmidt JF. Springfield: CC Thomas, 1959. p.115.</ref> Having this background knowledge, the incidence of crush syndrome was then observed in increasing numbers during World War II. During the London air raids many individuals experienced similar injuries, wherein Bywaters and Beall discussed the presentations of the syndrome. Statistically, out of 100 people with crush injuries, about 80 succumb to fatal head trauma or are not able to breathe underneath the rubble. Out of the remaining 20 that do reach the hospital, about 10 recover completely while 7 out of the other 10 proceed into developing signs of crush syndrome.<ref name="pmid2279155">{{cite journal| author=Bywaters EG| title=50 years on: the crush syndrome. | journal=BMJ | year= 1990 | volume= 301 | issue= 6766 | pages= 1412-5 | pmid=2279155 | doi=10.1136/bmj.301.6766.1412 | pmc=1679829 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2279155 }} </ref> A series of 11 cases where studied and differences between similar syndromes like crush and compartment syndrome were delineated in 1975.<ref name="pmid1192679">Mubarak S, Owen CA (1975) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1192679 Compartmental syndrome and its relation to the crush syndrome: A spectrum of disease. A review of 11 cases of prolonged limb compression.] ''Clin Orthop Relat Res'' (113):81-9. [http://dx.doi.org/10.1097/00003086-197511000-00012 DOI:10.1097/00003086-197511000-00012] PMID: [https://pubmed.gov/1192679 1192679]</ref> Main focus of managing crush syndrome is now to diagnose it earlier, to finalize a standard treatment with fluids to be administered to patients and to identify those who have extensive renal damage and would now require kidney replacement.<ref name="pmid15213274">{{cite journal| author=Gunal AI, Celiker H, Dogukan A, Ozalp G, Kirciman E, Simsekli H | display-authors=etal| title=Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes. | journal=J Am Soc Nephrol | year= 2004 | volume= 15 | issue= 7 | pages= 1862-7 | pmid=15213274 | doi=10.1097/01.asn.0000129336.09976.73 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15213274 }} </ref> | |||
==Pathophysiology== | |||
The complete pathogenesis of crush syndrome involves primarily two main events which in turn have several smaller steps that participate in their development. The trauma causes compression of a limb or region of the body, which if is present for two to three hours, leads to the process of rhabdomyolysis.<ref name="pmid8821813">{{cite journal| author=Zager RA| title=Rhabdomyolysis and myohemoglobinuric acute renal failure. | journal=Kidney Int | year= 1996 | volume= 49 | issue= 2 | pages= 314-26 | pmid=8821813 | doi=10.1038/ki.1996.48 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8821813 }} </ref> This in turn, causes renal damage and eventually renal failure if allowed to proceed.<ref name="pmid18284003">Sever MS (2007) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18284003 Rhabdomyolysis.] ''Acta Clin Belg'' 62 Suppl 2 ():375-9. [http://dx.doi.org/10.1179/acb.2007.084 DOI:10.1179/acb.2007.084] PMID: [https://pubmed.gov/18284003 18284003]</ref> | |||
*'''1. Compression induced rhabdomyolysis''' : | |||
**Increased local pressure causes the sarcolemma membrane to become permeable. | |||
**Substances move down their concentration gradient from the extracellular to the intracellular compartment and vice versa. | |||
**Water, sodium-Na+ and calcium-Ca2+ enter the cell while potassium-K+ and myoglobin enter the extracellular compartment. | |||
**As intracellular Ca2+ rises, muscular contraction ensues, emptying the cell’s ATP stores. | |||
**The ATP deficient cell causes mitochondrial damage along with release of enzymes like proteases and phospholipases. | |||
**These enzymes and oxidative stress, damage the phospholipids present in the cell membrane and as a result cause lysis of the muscle cell. | |||
**Toxic metabolites which were accumulating inside the cell are then released into the extracellular compartment. | |||
**These substances induce damage to the capillaries present in the area leading to leaking, which causes increased compartmental pressure due to third spacing of fluids. | |||
**Increased pressure in the compartment results in occlusion of these vessels and further depletion of energy sources like ATP and glycogen. | |||
**Decreased circulation causes reduced oxygen saturation of myoglobin. | |||
Revision as of 12:07, 24 June 2021
| Crush syndrome | |
| ICD-10 | T79.5 |
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| ICD-9 | 958.5 |
| DiseasesDB | 13135 |
| MeSH | D003444 |
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Crush syndrome Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Crush syndrome On the Web |
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American Roentgen Ray Society Images of Crush syndrome |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: Bywaters' syndrome; traumatic rhabdomyolysis
Overview
Being a common occurrence in victims of natural disasters and human wars, crush syndrome is still a rare finding in daily practice. Falling short to direct-fatal trauma, crush syndrome is the second most common cause of mortality after a disaster.[1] It is the sequalae that follows when an individual or a part of him/her has been crushed between two heavy objects and although it has a wide range of presentation like shock, trouble breathing, electrolyte disturbances and irregular beating of the heart, the main culprit behind these findings is the extensive damage to the kidneys as a result of the trauma the person was subjected to. This can be prevented with aggressive fluid resuscitation, but the sheer number of incoming trauma patients during a calamity plays a major role in creating logistic problems for the response teams and hence it becomes important to diagnose it earlier rather than later.
- Crush syndrome : also known as traumatic rhabdomyolysis or reperfusion syndrome, it is defined as the systemic features of a crush injury leading to renal failure.[2]
- Crush injury : the damage caused to muscle cells due to pressure applied on them locally, for a prolonged period of time.[3]
- Rhabdomyolysis : the breakdown and release of muscular tissue (myoglobin) into the bloodstream resulting in renal damage and the subsequent build up of toxic compounds in the blood.[4]
- Compartment syndrome : the raised pressure (>20 mm of Hg) within a localized region causing decreased local circulation which can lead to ischemia and necrosis of that osteo-musculo-fascial compartment.[5] This can later lead to release of necrosed muscle tissue into the blood which damages the kidney and can present with features similar to crush syndrome.
Historical perspective
The first reported relations between compressive trauma and renal damage were after the 1909 earthquake in Sicily and World War I.[6] In the year 1923, a physician named Seigo Minami reported crush syndrome after observing three soldiers who died due to renal failure as a result of injuries sustained during World War I. [7] Having this background knowledge, the incidence of crush syndrome was then observed in increasing numbers during World War II. During the London air raids many individuals experienced similar injuries, wherein Bywaters and Beall discussed the presentations of the syndrome. Statistically, out of 100 people with crush injuries, about 80 succumb to fatal head trauma or are not able to breathe underneath the rubble. Out of the remaining 20 that do reach the hospital, about 10 recover completely while 7 out of the other 10 proceed into developing signs of crush syndrome.[8] A series of 11 cases where studied and differences between similar syndromes like crush and compartment syndrome were delineated in 1975.[9] Main focus of managing crush syndrome is now to diagnose it earlier, to finalize a standard treatment with fluids to be administered to patients and to identify those who have extensive renal damage and would now require kidney replacement.[10]
Pathophysiology
The complete pathogenesis of crush syndrome involves primarily two main events which in turn have several smaller steps that participate in their development. The trauma causes compression of a limb or region of the body, which if is present for two to three hours, leads to the process of rhabdomyolysis.[11] This in turn, causes renal damage and eventually renal failure if allowed to proceed.[12]
- 1. Compression induced rhabdomyolysis :
- Increased local pressure causes the sarcolemma membrane to become permeable.
- Substances move down their concentration gradient from the extracellular to the intracellular compartment and vice versa.
- Water, sodium-Na+ and calcium-Ca2+ enter the cell while potassium-K+ and myoglobin enter the extracellular compartment.
- As intracellular Ca2+ rises, muscular contraction ensues, emptying the cell’s ATP stores.
- The ATP deficient cell causes mitochondrial damage along with release of enzymes like proteases and phospholipases.
- These enzymes and oxidative stress, damage the phospholipids present in the cell membrane and as a result cause lysis of the muscle cell.
- Toxic metabolites which were accumulating inside the cell are then released into the extracellular compartment.
- These substances induce damage to the capillaries present in the area leading to leaking, which causes increased compartmental pressure due to third spacing of fluids.
- Increased pressure in the compartment results in occlusion of these vessels and further depletion of energy sources like ATP and glycogen.
- Decreased circulation causes reduced oxygen saturation of myoglobin.
- ↑ Sever MS, Vanholder R (2011). "Management of crush syndrome casualties after disasters". Rambam Maimonides Med J. 2 (2): e0039. doi:10.5041/RMMJ.10039. PMC 3678930. PMID 23908797.
- ↑ Michaelson M. (2009) Crush Injury, Crush Syndrome. In: Shapira S.C., Hammond J.S., Cole L.A. (eds) Essentials of Terror Medicine. Springer, New York, NY. https://doi.org/10.1007/978-0-387-09412-0_20
- ↑ Michaelson M. (2009) Crush Injury, Crush Syndrome. In: Shapira S.C., Hammond J.S., Cole L.A. (eds) Essentials of Terror Medicine. Springer, New York, NY. https://doi.org/10.1007/978-0-387-09412-0_20
- ↑ Torres PA, Helmstetter JA, Kaye AM, Kaye AD (2015). "Rhabdomyolysis: pathogenesis, diagnosis, and treatment". Ochsner J. 15 (1): 58–69. PMC 4365849. PMID 25829882.
- ↑ Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/
- ↑ Better OS (1990). "The crush syndrome revisited (1940-1990)". Nephron. 55 (2): 97–103. doi:10.1159/000185934. PMID 2194135.
- ↑ Medical discoveries - Who and when- Schmidt JF. Springfield: CC Thomas, 1959. p.115.
- ↑ Bywaters EG (1990). "50 years on: the crush syndrome". BMJ. 301 (6766): 1412–5. doi:10.1136/bmj.301.6766.1412. PMC 1679829. PMID 2279155.
- ↑ Mubarak S, Owen CA (1975) Compartmental syndrome and its relation to the crush syndrome: A spectrum of disease. A review of 11 cases of prolonged limb compression. Clin Orthop Relat Res (113):81-9. DOI:10.1097/00003086-197511000-00012 PMID: 1192679
- ↑ Gunal AI, Celiker H, Dogukan A, Ozalp G, Kirciman E, Simsekli H; et al. (2004). "Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes". J Am Soc Nephrol. 15 (7): 1862–7. doi:10.1097/01.asn.0000129336.09976.73. PMID 15213274.
- ↑ Zager RA (1996). "Rhabdomyolysis and myohemoglobinuric acute renal failure". Kidney Int. 49 (2): 314–26. doi:10.1038/ki.1996.48. PMID 8821813.
- ↑ Sever MS (2007) Rhabdomyolysis. Acta Clin Belg 62 Suppl 2 ():375-9. DOI:10.1179/acb.2007.084 PMID: 18284003